Post on 22-Mar-2017
Carpal Tunnel Syndrome
Carpal Tunnel SyndromeDr. Amith Kamath MBBS
Definition
Compression neuropathy of the median nerve in wrist area ( tardy median nerve palsy)
Described in 1854 by Sir James Paget
The median nerve travels from the forearm into your hand through a tunnel in the wrist.
Anatomy
Etiology1- Primary or Idiopathic2- Secondary A: Local etiology I: Anatomical malformation II: Tumors III: Infections IV: Bone prominence B: Systemic Etiology Obesity, Diabetes Mellitus, Thyroid Dysfunction ,R.A ,DM, Pregnancy
MNEMONICPRAGMATICP-PREGNANCYR-RHEUMATOID ARTHRITISA-ATHRITIS DEGENERATIVEG-GROWTH HORMONE EXCESS i.e. ACROMEGALYM-METABOLIC i.e. GOUTA-ALCOHOLISMT-TUMORSI-IDIOPATHICC-CONNECTIVE TISSUE DISORDER i.e. AMYLOIDOSIS
Clinical stagesStage 1 Pain Morning stiffness of hand
Stage 2-localised to supply of median nervePainTinglingNumbnessParaesthesia
Stage 3Clumsiness of hand Impairment of digital function
Stage 4Sensory loss in the area of median nerve distribution obvious wasting of thenar muscles
Thenar muscle wasting due to continued pressure
Diagnosis History Clinical examination I: Median nerve percussion test II: Phalen's wrist flexion test III: Tourniquet test IV: Median nerve compression test Others2 point discrimination testElectrodiagnostic test
Phalens testPatients is asked to actively place the wrist in complete but forced flexion+ve if tingling and numbness is produced in 60 sec.Sensitive and specific in 80%
Median nerve percussion testExaminer gently taps over the median nerve at the wrist+ve numbness n paraesthesia
Tourniquet testBP cuff tied proximal to elbow and inflated higher than patients Systolic BP. +ve if numbness and paraesthesia
Median nerve compression testDirect pressure is exerted over both wrist 1st phase time taken for symptoms appear(15-20sec)2nd phase-time taken for symptoms to disappear after release of pressure
Treatment1- Non surgical treatment2- Surgical treatment Endoscopic release 1- Age over 50 2- Duration longer than 10 months 3- Constant paraesthesia4- Stenosing flexor tenosynovitis5- Positive Phalens test less than 30 seconds
NSAIDsSteroids- Prednisolone for 8days, 40mg for 2days n taper by 10mg for next 2days
Carpal tunnel splint
Injection-infusion of cortisone with splinting for 3weeks
Surgical treatment
Open or endoscopic (similar success)
Consists of division of flexor retinaculum and transverse carpal ligament
Surgical Complication 1- Infection2- Nerve injury 3- Reflex Sympathetic Dystrophy4- Painful scar 5- Bowstringing6- Muscle weakness7- Skin necrosis
Dupuytrens Contracture
Dupuytrens contracture is defined as proliferative fibroplasia of subcutaneous palmar tissue, forming nodules and cords along its ulnar border.
This fibroplasia results in finger contracture, thinning of subcutaneous fat, pitting of skin, and knuckle pads on dorsum of proximal inter phalangeal joint
Etiology
HereditaryTrauma chronic & repetitive in natureOccupational-rock drillingMore in malesWhitesEpileptics and alcoholics
Structures Involved
Palmar fasciaPretendinous bandsSuperficial transverse ligamentSpiral bandNatatory ligamentLateral digital sheathGraysons ligamentCleelands ligament
Clinical Features
Grades
TreatmentObservation-consists of no Rx with observation being done at every 3 months
Radiotherapy-only during fibroblastic phase
Surgical-Depends on degree of contracture
Surgical Methods
Subcutaneous Fasciotomy-in elderly,arthiritisPartial Selective Fasciotomy-when 2 fingers are involvedComplete Fasciotomy- rareHematoma, Joint stiffnessFasciotomy with skin grafting-young people with epilepsyResection and arthrodesis-severe contracture of Proximal Inter Phalengeal JointAmputation
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